RESPONSI

MASTITIS
Preceptor :
Dr. dr. Bambang Arianto, Sp.B.

Compiled By:
Muhammad Fajar Trenggalih 201720401011127
Soraya Fadhilah 201720401011122

HAJI GENERAL HOSPITAL SURABAYA

MEDICAL FACULTY
MUHAMMADIYAH MALANG UNIVERSITY
2018
 IDENTITY

Mrs M female 28th

Surabaya Housewife

Hospitalized time : 24/01/18,

Examination time : 24/01/18
 SUBJECTIVE

Chief Complaint : Right breast

swelling and pain

Additional Complaint : -
 History of Present
Illness

Came to hospital 24-1-18

Right breast swelling and pain since 1 week ago, right breast
nipples swelling since 3 days ago. Previously about 2 weeks ago,
there was a lump on the top of the breasts as big as marbles and
had broken out after 1 week appeared the bump and drain pus.
After that breast feels swollen and pain, then right nipple swelling,
currently the patient is breastfeeding. Patients admitted hot since
the first bump appeared, then after the lump broke the heat down,
but when the swollen nipple the patient experiencing heat again.
History of Past Illness
Allergy :-
Medication : -
Past Illness :
•longer cough history (-),
•DM (-), HT (-),
Birth History

 G2P2A0
 Second child 2 months
 BBL / PBL: 350gr / 50cm
 Directly crying - Breast milk smoothly before the breast
is swollen
 OBJECTIVE

General status
 VITAL SIGN

130/8 90x/b 18x/

38.7 C
0 pm min
mmHg
 PHYSICAL EXAMINATION

Head : Anemia(-)/Ikterus (-)/ Cyanosis (-) / Dyspnea (+)

Neck : Deviation of Trachea (-)

Enlargement of Lymph Node (-)
Enlargement of thyroid(-)
Thorax :
- Cardiac:
I = Ictus cordis is not visible
P = Ictus is not palpable
P = normal heart
A = Single S2 S1, Murmur (-),
Gallop (-)
Thorax :

PULMO
 I = Symmetrical, normochest, retraction (-), lesion (-)
 P = Movement of simteris chest wall, crepitation (- / -)
 P = Sonor / Sonor
 A = Vesicular / vesicular, Rh - / -, Wh - / -
Abdomen

Inspection : flat
Auscultation : bowel sound (+) N
Palpation : Soepel, tenderness (-)
Percussion : tympani

Ekstremity
 LOCAL STATUS
Aerolar-
Inspection (Look): Aerolar mammae edema (+) of ping-
pong ball (3cmx3cmx3cm), mobile not attached to base,
inflammation mark (+), clear boundary
Palpation (Feel): Smooth, firm, and tender (+) emphasis
on the mammary nipple. The right Mammae is denser
than the left mammae
 LAB FINDING
Complete Blood Count
- Leukosit : 26,690 /mm3
- PLT : 393,000 /mm3
- Hb : 10,1 g/dl
- Hct :31.6%
Clinical Chemistry
- GDA Stick : 105 mg/dl (<150)
- Natrium : 134 mmol/L (136-
145)
- Klorida : 103 mmol/L (996-
106)
- Kalium : 3,9 mmol/L (3,6-5,0)
 ASSESMENT

Working Diagnosis : Mastitis Mamae Dextra + SIRS

Primary Diagnosis : Mastitis Mamae Dextra
Secondary Diagnosis:-
Tertiary Diagnosis : SIRS
 PLANNING
Diagnosis : - FNAB

Therapy :
- Inj. Antibiotics
- Treat Injuries
- compress the mammae with PZ
- Diet High Calorie high protein
 PLANNING
Monitoring :
- Vital sign (PR, RR, temp, BP)
- Patient complaints (pain and fever)
- General medical state monitoring

Education :
- Tell that patient and his familly about patient condition.
- Tell that patient and his familly about the examination and
therapy.
FOLLOW UP
24/01/18


S: The patient complains of pain in the nipple mammae,
nausea (-), vomitting (-), headache (-), febris (-),
dyspneu (-).
FOLLOW UP
24/01/18
 O: Awareness: Compos Mentis; GCS: 4-5-6 TTV: TD:
120/80 mmHg; N: 110 bpm; RR: 20 x / m; Q: 38.7 oC
 Generalist Status:
o Head and Neck: a / i / c / d: - / - / - / -
o Thorax: symmetrical Heart: S1 single S2
Lung: versicular + / +
o Abdomen: Flat, supel, intestinal sis (+) normal
o Ektremity: warm
FOLLOW UP
24/01/18

Local Status (Regio Areolar mammae edema (+) size of ping pong
ball (3cmx3cmx3cm), mobile not attached to the base, inflammation
mark (+), clear boundary
Palpation (Feel): Smooth, firm, and tender constituency (+) on the
mammae putting. Mammae is denser than the left mammae
A: Mastitis Mamae Dextra + SIRS

P:
Inf. RL : RD5 (2:1) 1500 cc/24 hours
Inj. Ceftriaxone 2x1 mg
Inj Antram 3x1 mg
Treat Injuries
Kompres mammae dengan PZ
Diet High Calorie high protein
FOLLOW UP
26/01/18
 S: Fever (-), pain in right breast (-)
 O:
  Generalist Status
 GS: weak GCS 4-5-6
 o TD: 120/70 mmHg
 o N: 96 x / min
 o RR: 18x / min
 o Q: 36.7ºC
 o Head and Neck: a / i / c / d: - / - / - / -
FOLLOW UP
25/01/18
 o Thorax: symmetrical
 Heart: S1 single S2
 Lung: versicular + / +
 Abdomen: Flat, supel, intestinal sis (+) normal
 Ektremitas: Akral warm
 Local Status
 Inspection (Look): Areolar mammae edema (+) Size of
ping pong ball (3cmx3cmx3cm), mobile not attached to
the base, inflammation mark (+), clear boundary
 Palpation (Feel): Smooth, firm, and tender (+) emphasis
on the mammary nipple. Mammae is denser than the left
mammae
FOLLOW UP
25/01/18
 A: Mastitis Mamae Dextra + SIRS
 P:
 Inf. RL : RD5 (2:1) 1500 cc/24 hours
 Inj. Ceftriaxone 2x1 mg
 Inj Antram 3x1 mg
 Treat Injuries
 Kompres mammae dengan PZ
 Diet High Calorie high protein
FOLLOW UP
26/01/18
 S: Fever (-), pain in right breast (-)
 Generalist Status
 Awareness: enough GCS 4-5-6
 o TD: 130/80 mmHg o N: 86 x / min o RR: 18x / min
 o Q: 37.1ºC o Head and Neck: a / i / c / d: - / - / - / -
 o Thprax: symmetric Heart: S1 single S2 Lung:
versicular + / +
 o Abdomen: Flat, supel, intestinal sis (+) normal
 o Extremity: warm
FOLLOW UP
26/01/18
 Status Lokalis (region mammae dekstra)
Inspection (Look): ulcers (+) ± 2cm, mammary edema felt warm
and painful, areola edema (+)
Palpation (Feel): Mammae is denser than the left mammae

 A: Mastitis Mamae Dextra + Abses Mammae Infiltrat

 P:
 Inf. RL : RD5 (2:1) 1500 cc/24 hours
 Inj. Ceftriaxone 2x1 mg
 Inj Antram 3x1 mg
 Treat Injuries
 Kompres mammae dengan PZ
 Diet High Calorie high protein
FOLLOW UP
27/01/18
 S: Fever (-), pain in right breast (-)
 0:  Generalist Status
 Awareness: Cm GCS 4-5-6o TD: 120/80 mmHgo N: 90 x /
mino RR: 18x / mino Q: 36.7ºC
 o Head and Neck: a / i / c / d: - / - / - / -
 o Thprax: symmetric
  Heart: S1 single S2
  Lung: versicular + / +
 o Abdomen: Flat, supel, intestinal sis (+) normal
 o Extremities: warm
Local Status (region of right hand mammae)
o Inspection (Look): ulcers (+) ± 2cm, warm and painful
edema mammary, edema areola (+) decreased
o Palpation (Feel): Mammae dextra is denser than the
mammae Sinistra
A: Mastitis Mamae Dextra + Abses Mammae Infiltrat
P:
Inf. RL : RD5 (2:1) 1500 cc/24 hours
Inj. Ceftriaxone 2x1 mg
Inj Antram 3x1 mg
Treat Injuries
Kompres mammae dengan PZ
Diet High Calorie high protein